Excision with Immediate Suture is almost exclusively applied to those cases of small fistulous tracts of the complete external variety which are short and straight in their course. A long pliable silver probe should be introduced through the entire canal. It may then be used as a tractor when coiled upon itself. The tractor thus formed should permit the lifting of the fistula and surrounding tissue from the level of the skin. The operator may then cut beneath and around the fistula so as to remove it entirely from its former bed. A small piece of mucous membrane should be dissected loose from the rectum and pulled down to cover the rectal end of the wound. Two separate sutures should be inserted at each corner of this mucous membrane flap to hold it in a position to cover the wound sutures. This is done to prevent infection from the rectum. Several tiers of plain catgut, either continuous or mattress, sutures should be introduced within the interior of the wound so as to close it tightly. If necessary, the divided ends of the sphincter should be first brought together by two or three interrupted catgut sutures. The skin should not be penetrated during the operation, as infection is very likely to follow, due to the inability to render it sterile. The wound should then be sealed with chloroform-collodion to add further protection against infection. Anesthetics. Before operating on the minor cases of phis-tulae the question as to whether the patient should receive a general anesthetic, or whether local anesthesia may suffice, is to be considered. Cocaine is the time worn drug for this held of operation, and when used in a total quantity not over one-fourth of a grain has proven a safe and painless local anesthetic. Eucalypti is next in the order of experience and usefulness and is most extensively used by some for this class of work. Quinine and urea hydrochloride has recently been introduced into the field of rectal anesthesia and promises to prove a superior drug for its absolute non-toxic effects, and for the complete anesthesia which it affords. My experience has been with solutions varying from one to five percent. I have found it very effectual. The only drawback to quinine and urea hydrochloride is that the anesthesia is not produced as rapidly as in the administration of cocaine or eucalypti The disagreeable shock, symptoms and pain following the use of cocaine and eucalypti are most fortunately not apparent after the use of quinine and urea hydrochloride. This is probably due to the effect of the anesthesia of the latter lasting for so many hours after the operation.

Fig. 43. Excision of fistula, first step.

Local anesthesia is the only means by which one may operate on those subjects suffering from heart, kidney or lung diseases, which prohibit the use of a general anesthetic. Further, some persons who are unable to spare the time from business or other occupations, or who object to general anesthesia, can only be treated by such methods. When the fistula is short or superficial they can be successfully treated at home or in the office. The use of liquid air has been suggested and it would seem a very satisfactory agent for this purpose. The ether spray, ethyl chloride, or other freezing agents are attended with considerable pain before and after the effect of the drug has worn off, and are not recommended when other agents can be used.

Fig. 44. Excision of fistula, second step.

In the division of a fistulous tract which involves the cutting of the external sphincter muscle, whether it be a complete or incomplete fistula, care should be taken in each instance that when the incision is carried through the muscle it is made at right angles and not obliquely. The same general principle should be adhered to, if possible, when traversing the gluten region, in severing the elevator an for a fistulous tract, or, when giving vent to an abscess formation. The idea suggested is for the purpose of preserving the muscular plane so that when granulation take place there is a firm regular scar to take the place of the tissue and also that the muscle bands are not irregularly severed as might be with the oblique incision, thereby avoiding incontinence.

Fig. 45. Excision of fistula. Method of introducing sutures.

Treatment for Complete Fistula. After the rectum has been washed out and the parts sterilized as well as can be done in this region, a grooved director is introduced into the outer opening and passed through the fistulous tract into the rectum. Care should be exercised that the inner opening has been f≪ >ind, the director not permitted to penetrate the surrounding tissue, and an inner opening made which did not exist before. This may be guarded against by the finger in the rectum acting as a guide. Then, with a knife or a scissors, the entire overlying tissue resting upon the director is divided at right angles to the muscle, avoiding if possible a cut of the zing-zag form, or an oblique incision.

Some authors advocate what is known as Salmons' back-cut, which is an incision carried backward from the bed of the fistula. This is supposed to help the subsequent granulation but does not meet the approval of most surgeons, as it is unnecessary. A curettage, with a sharp curettage, should be thoroughly and effectively done through all the tract. After this the wound should be sterilized with alcohol, if the tract is not sutured immediately. Loose packing should be introduced to control hemorrhage, a morphine suppository and a drainage tube inserted; then a sterile dressing applied. Should the incision have been so extensive as to leave a large wound, adhesive plaster may be applied over the dressing to keep it secure.